The patient is a 63 year old male who originally came to their primary physician’s office complaining of abdominal pain.

Coding Scenario: The patient is a 63 year old male who originally came to their primary physician’s office complaining of abdominal pain. Outpatient imaging demonstrated a cecal mass and a subsequent colonoscopy with a biopsy revealed poorly differentiated adenocarcinoma. A PET scan did not show any distant metastases. The lesion was tattooed for later definitive treatment. The patient now presented for elective treatment for the cancerous lesion. He underwent a laparoscopic colectomy of the cecum with anastomosis without any complications. There was no evidence found for any other suspicious lesions or metastases. The liver had a small cyst on the left lobe, but no other abnormalities. The patient had a fairly routine postoperative course. The patient was noted to have minor and expected acute blood loss anemia from the surgery. This was monitored and managed, and ultimately transfusions were not needed. Bowel function returned. However, three days after surgery the patient did have some dyspnea. Chest imaging didn’t reveal anything significant and the patient was determined to have had a small acute exacerbation of their chronic systolic heart failure. The patient has a history of methamphetamine abuse, but the drug screens here have been negative. The patient was gently diuresed. Other chronic conditions that were managed during this admission were their hypertension and hypothyroidism. The patient was a bit hyperglycemic from initial labs, but the AlC didn’t reveal diab etes . Thereafter the patient was discharged on day five to follow up with his gastroenterologist and oncologist in the next two weeks.

Assignment=

Code the principal diagnosis and any secondary diagnoses for the above case scenario using the ICD-10-CM Code Book and then code it again using the 3M Encoder from the vLab.

What reimbursement system would be used for this case?  Provide the reimbursement codes you obtained from the Encoder (APC, DRG, etc.). 

 Identify any ICD-10-CM coding guidelines that you applied while coding the scenario.   

Provide your index entries (how you got your codes) as follows.

Principal Diagnosis:

Index entries:

Rationale:

Secondary diagnosis code(s):

Index entries:

Rationale:

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